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Applications Will Be Pr."d When Submitted Property Completed. Be Sure T•9n The Appll"tlon. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT GENERAL <br /> ENGINEER?AND/OR APPLICATION IF VEHICLEJNVOLVED,GIVE <br /> APPLICANT'S ANIVOq <br /> Make <br /> CONTRACTOR AND/OR ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> BROKER ANaOR Lid.No. <br /> UCENSE ANDIOR 0000 ESTASUiMMEST;HOUSING <br /> REGISTRATION PU6 IC 1141011,MATES SAMPUNC Regist.No. _ <br /> N BER HEAL ESTATE INSPECTIONS Color <br /> POULTIT KAKCMES AND KENNELS <br /> MISCELLANEOUS SESWCES �d^✓�G� <br /> rApplication Date 7 �" Busi ass/�t a To Appear On P rm' 29t 4 <br /> !Property <br /> Type Permit/Service R ested: .•+�✓' �'�''� "��Applicant Name fIGC'� Address 4 � GZ� a4f e . 3?57LW' usiness elephone o.� J('P& T7 Emergency Telephone Localion/A r a' <br /> JProperty Owner Address 6a T/ <br /> LOperator's Name / Address •3G9 <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant,Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PUNT ❑ COMMISSARY ❑ ICE PUNT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIOUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/NO.of ❑ MOBILE FOOD PREP.UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No.of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2 HOUSING <br /> ❑ HOTEUMOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No.of Spaces <br /> i WATER QUALITY ❑ WATER SAMPLE(Bacterial) ❑ CHEMICAL <br /> ❑ PURLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO.OF PUBLIC SERVED(Connections) <br /> e. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No.of Birds <br /> ❑ KENNEL/Runways /Animal Population No. No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source a Animal Waste Disposal Method <br /> O. CONSULTATION FEE 7aWflz L ❑ BUSINESS LICENSE <br /> T. ❑ PLAN CHECKING FEE ❑ DANCE PERMIT <br /> S. REAL ESTATE <br /> REQUEST: Water Well Inspection 13 Sample❑ Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. <br /> Seller Seller Address <br /> Telephone No. Seller Agent Name <br /> Service Request For Dale <br /> I hereby.certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances.state laws.and rubs and regulations of the San Joaquin Local Health District r, <br /> C' 6 <br /> APPLICANT'S SIGNATURE - ' - 'i-EY`<Titl ' Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jemury 1 A Rsce w By J..,y St ❑July I A Recen.d ey Jmh st <br /> BILLING REMITTANCE f REMIT <br /> BASE EXPLANATION BILLING WE CHECKED <br /> n / DATE DATE REMITTED AMOUNT <br /> FEE �/� •I !�'f '11.6 i'L' ©•d G-) <br /> LESS <br /> PRORATION <br /> Rus <br /> PENALTY <br /> OTHER <br /> OTHER KL <br /> R.C.ive6 tM DeM Realpl N0. Pereln No. I..wmE.au w6.d DMiveled i <br /> AMICAIIT—eETIMxlO1 fAIJFJt'TP. ENVIAONMENTAL HEALTH PEAMITMEMVICES 1001 E.NAEELTON AVE..P.O.Nes alas aTOCKTOM.CA 063101 � <br />